Provider Demographics
NPI:1417331067
Name:WONG, PHILLIP (DMD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9732 NW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1030
Mailing Address - Country:US
Mailing Address - Phone:317-593-5375
Mailing Address - Fax:
Practice Address - Street 1:9732 NW 32ND ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-1030
Practice Address - Country:US
Practice Address - Phone:317-593-5375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2025-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012872A1223G0001X
FLDN300001223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral Practice